A comparison of computed tomography, X‐ray and Lodox^® scans in assessing pediatric skull fractures using piglets

Abstract

Skull fractures are common in children both due to abuse and accidental incidences. The accurate detection of these fractures may therefore be critical. The aim of this study was to investigate the reliability of CT, X‐ray, and Lodox® scans, the latter which has not previously been evaluated and is commonly employed in South Africa, in detecting the number, location and type of pediatric skull fractures. Blunt force trauma was inflicted with a mallet on ten piglet skulls, which were CT, X‐ray, and Lodox® scanned and then macerated. The number, location, and type of skull fractures visible using each imaging modality, and on the cleaned skulls, were recorded. Sensitivities and specificities of each method were calculated. For fracture number and location, CTs had a sensitivity of 47.3%, X‐rays 22.4% and Lodox® 23.3%. For fracture type, sensitivities were 46.1%, 16.6%, and 17.8% for CT, X‐ray, and Lodox®, respectively. Specificities were high (92.5%–100%) which reduces the risk of incorrectly diagnosing fractures. However, low sensitivities increase the risk of failing to identify fractures and possible victims of abuse. Osteological analysis should preferably be the method of choice when evaluating pediatric skull trauma, and CTs should be used when osteological analysis is not feasible. If CT scanners are not available, X‐rays and Lodox® may have to be used. In these cases, additional radiographic views of the skull are imperative and may increase the sensitivity of these methods, although they are not recommended to detect exact pediatric skull fracture number, location, and type.

The Role of Radiology (X-Ray versus Computed Tomography) in Medicolegal Cases Presented at a Tertiary Care Hospital in Pakistan

“…18 In contrast to our findings, a study by Spies et al, reported that the use of X-rays had a sensitivity of only 22.3% as compared to CT scan which was found to be 47.3% sensitive. 19 Studies in the past have reported lower sensitivity of CT scans as compared to the present study, which may indicate advancements in radiological techniques or the involvement of more experienced radiologic consultants.…”

Diagnostic accuracies of CTs, X-rays and Lodox to detect blunt force trauma in adults, using a pig model

“…When compared to piglets, CTs are more sensitive in adult-sized pigs, detecting 58.2% of skull fractures in pigs compared to only 47.3% in piglets. (44) However, sensitivities for X-rays and Lodox are comparable between adult-sized pigs and piglets, both detecting approximately 1/5 th of fractures in both models. (44) The inability of X-rays and Lodox to detect fractures of the skull, and the fact that CTs fail to identify approximately 40.0% of these fractures, is concerning since blows to the skull are extremely common in incidences of violent crime.…”

“…Skeletal trauma is often evaluated using radiological means, and knowledge of the diagnostic capabilities of these methods in detecting fractures is essential. While some studies have compared the sensitivities of various imaging modalities against the number of fractures detected on the cleaned skeletons, (23,(42)(43)(44) these studies all assessed BFT in human infants or piglets as proxies for human children. However, the bones of adults and children differ in size, composition, elasticity, and strength, (45) and the radiological detection of skeletal trauma may differ between them.…”

“…Specificities are similar to those reported for adults in previous studies, (33,34,36,39,41) and similar to those reported for skull fractures in piglets (97.7% -100.0%). (44) PPVs are high for all modalities and all regions (all above 80.0%) which indicates that a fracture detected by any modality is highly likely to indeed be a true-positive identification. NPVs are much more variable, indicating highly variable probabilities that a fracture not detected by a radiological method is indeed a true-negative identification.…”

“…Cattaneo et al (42) and Mulroy et al (43) both compared the sensitivities of CTs and X-rays using the defleshed bones as the gold standard, finding CTs to be most sensitive for skull, rib and limb fractures. In a comparison of CT, X-ray and Lodox in piglet carcasses, Spies et al (23,44) found that CTs detected significantly more fractures in all body regions compared to X-ray and Lodox. Similarly, Spies et al (23) also found CTs to be significantly more sensitive than both X-ray and Lodox in determining the minimum number of blows incurred.…”